NURS 420- Final Exam Questions With Complete Solutions

NURS 420- Final Exam Questions With Complete Solutions 18 year old unrestrained passenger with multiple injuries should be treated at what trauma level - - answerlevel 1 the nurse is caring a patient with severe sepsis who was resuscitated with 3000ml of lactated ringer solution over the past 4 hours. morning laboratory results show a hemoglobin of 8g/dl and a hematocrit of 28%. what is the best interpretation of these findings by the nurse a. blood transfusion with packed red blood cells is required b. hemoglobin and hematocrit indicates hemodilution c. fluid resuscitation has resulted in fluid volume. overload d. fluid resuscitation has resulted in third-spacing of fluid - answerb. hemoglobin and hematocrit indicates hemodilution the nurse is caring for a patient admitted following a motor vehicle crash. over the past 2 hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. to prevent complications, what is the priority nursing intervention: a. administer pain medication b. turn patient every 2 hours c. assess core body temperature d. apply bilateral heel protectors - answerc. assess core body temperature the nurse is administering both crystalloids and colloid intravenous fluid resuscitation in a patient admitted in severe sepsis. what findings assessed by the nurse indicates an approbate response to therapy: a. normal body temperature b. balanced intake and output c. adequate pain management d. urine output of 0.5 ml/kg/hr - answerd. urine output of 0.5 ml/kg/hr the nurse is caring for a patient admitted with the early stages of septic shock. the nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18 - answerd. pH 7.30, CO2 45, HCO3 18 trauma nurse is common for the older trauma client - - answerfalls are leading cause of death, physiology is a good indication of outcome, & hypotension in the elderly (chronic disease not effect & fractured hips are uncommon) fluid resuscitation what do you monitor / whats trending - - answerserum lactate levels admitted client who fell from the 1st floor and smells of alcohol begins vomiting - - answerprepare to suction while holding spine immobilization the nurse is caring for a patient who has diminished level of consciousness and who is mechanically ventilated. while performing endotracheal suctioning, the patient reaches up in attempt to grab the suction catheter. what is the best interpretation by the nurse: a. the patient is exhibiting extension posturing b. the patient is exhibiting flexion posturing c. the patent is exhibiting purposeful movement d. the patient is withdrawing to stimulation - answerc. the patent is exhibiting purposeful movement while caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mmHg and a CPPof 85 mmHg. what is the best interperation by the nurse: a. both pressures are high b. both pressures are low c. ICP is high; CPP is normal d. ICP is high; CPP is low - answerc. ICP is high; CPP is normal the nurse is caring for a patient admitted with shock. the nurse understands which assessment finds the best assess tissue perfus